Building protocols into EHRs can help cut wasteful care

MRIs, CT scans and X-rays for low back pain patients dropped by half last year at the UPMC health system in Pittsburgh after doctors started seeing reminders in the electronic health record that such tests can be unnecessary.

UPMC incorporated the reminders into its EHR, drawing from the Choosing Wisely recommendations from the American Academy of Family Physicians and two neurological surgical societies to avoid spine imaging for “nonspecific acute low back pain and without red flags.” The pathway directs these patients to rest or physical therapy first, said Dr. Steven Shapiro, UPMC executive vice president and chief medical and scientific officer.

Use of CT scans, MRIs and X-rays at UPMC dropped 52% in 2014 compared with 2012. Spending on imaging dropped $2.8 million and spine surgery fell by 5%.

More than 70 medical societies have recommended more judicious use of roughly 430 medical tests and interventions since the American Board of Internal Medicine Foundation launched its Choosing Wisely campaign in 2012. The campaign first focused its efforts on public education, but it will increasingly push to change the practice of medicine, said Daniel Wolfson, the foundation's executive vice president.

But tracking unnecessary care and getting clinicians to change their behavior has proven difficult. Tracking overuse has been hampered by uneven use of EHRs, which hold the most detailed information about medical history and symptoms. That detail is valuable to identify which patients are not likely to benefit from certain treatment. Claims data offer less information. Incentives to reduce overuse remain weak without well-developed measures of performance.

“Measuring these services in claims is difficult and imprecise,” said Carrie Colla, an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice.

Even at hospitals and medical groups with sophisticated health IT systems, identifying unnecessary services is complicated by the difficulty of figuring out which patients might benefit from those services in at least some cases. And once unnecessary care is definitively identified, no one is sure how best to change physician behavior or patients' expectations to reduce use.

Health systems are using various strategies to try to change physician behavior once overuse is identified. These include pay-for-performance, quality measurement and reporting, and electronic decision support. But evidence for each method is weak, Colla said.

Recent estimates of overuse of medical services in the U.S. have ranged widely. The Institute of Medicine estimated that waste accounted for $765 billion, or about 30% of the nation's $2.5 trillion healthcare tab in 2009. Of the wasted spending, the IOM said, $210 billion consisted of unnecessary care. Last year, an article in JAMA Internal Medicine estimated from 9.1 million to 21.9 million cases of overused services for Medicare patients in 2009. A separate analysis using 2012 Medicare data found between $1.9 billion and $5.8 billion in spending because of overuse of 26 services, including imaging for low back pain.

Some health systems, such as UPMC, have started tracking overuse and devising strategies to stop it. The ABIM Foundation awarded seven grants this year to test use of some Choosing Wisely recommendations by doctors and hospitals. The seven groups will work to reduce use of antibiotics to treat viruses, along with targeting at least two other areas of overuse. Wolfson said the grants provide support for changing the behavior of doctors and patients.

But the number of Choosing Wisely recommendations that providers have tackled through data analytics, practice guidelines and financial incentives has been limited so far. Researchers and physicians are grappling with how to transform “well-intentioned statements” from the Choosing Wisely program into useful measures, said Dr. Thomas Sequist, chief quality and safety officer for Partners HealthCare in Boston.

For example, one Choosing Wisely recommendation urges doctors not to perform a stress test on patients with stable heart disease. Patients who are low risk and asymptomatic don't need the test, Sequist said. But which patients are low risk and what symptoms should trigger stress testing? Dizziness? Chest pain? Without greater clarity, doctors could make the wrong recommendations and either fail to curb overuse or deny needed care, he cautioned.

At UPMC, it helps that the system owns a health plan and pays doctors based partly on how closely they stick to protocols, which include some Choosing Wisely recommendations. One-quarter of physician incentives are related to quality, and adherence to protocols is one measure of performance, Shapiro said. Too often, healthcare fails to follow strong evidence for good care, where such evidence exists. “That's not acceptable,” he said.